The value of a health scheme

The challenges for the success of Ayushman Bharat are more than just at the financial and infrastructural level

On September 24, the government launched the grand government-funded healthcare scheme, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY). While some see its ambitious goals as its main strength, others are sceptical given the inadequate funding for the scheme, the weak infrastructure of primary health care centres, and the time required for the goals to be accomplished. However, nobody disputes the imperative of an insurance scheme as vast as the PMJAY, since every year about 36 million families, or 14% of households, face a medical bill that is equal to the entire annual living expenses of one member of the family. This frequently pushes many families into penury.

Two schemes, one focus

The euphoria over this scheme is reminiscent of the excitement over the Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008. Although the PMJAY is much wider in its reach than the RSBY (it covers 50 crore beneficiaries with ₹3,500 crore of government spending and provides benefits up to ₹5 lakh per eligible family), the central framework is the same: universal health care and health rights. The emerging discourse surrounding the PMJAY scheme resonates with those of RSBY. The focus continues to be on the top-down, deductive reasoning of the scheme, including issues such as allocation of funds for each illness, the types of care provided, financial considerations for empanelment of hospitals, types of illnesses covered, and transaction costs. These considerations matter. However, there are important missing links.

Vani S. Kulkarni

My recent study of RSBY in Karnataka yielded important insights that are pertinent here. Given that RSBY was embedded within the framework of universal health care and health rights, it is appropriate to pay attention to the existence of health rights in a local set-up. I discovered that the way beneficiaries of RSBY (Below Poverty Line households) perceived the scheme was not as a health right but in terms of the value it imparted, which was measured along multiple dimensions.

Households initially measured the value of the RSBY in terms of its material benefit and measurable impact. This included the financial ease it provided in taking care of illnesses, the expense and types of illnesses that the card covered, and the transaction costs it entailed — how easy it would be to use the card in terms of bureaucratic paperwork and formal procedures.

Beyond the visible impact

However, households also valued the RSBY beyond its visible impact. They had little value for the RSBY because of many reasons. One, officials who distributed the RSBY smart card did not provide information on how to use the card. Two, hospitals did not respect patients with the card, believing that they were availing medical care free of cost. Sometimes they did not honour the card either due to inaccuracy of fingerprints or lack of money on the card. Three, neighbours and family members did not discuss the utilisation of the card, making households perceive the card as just a showpiece: important to possess but not useful. Four, the lack of involvement and endorsement by local leaders further diminished the value of the card for the households.

The value of the RSBY was also derived in relation to the value of health itself. The difficulty in understanding the basic facts of the card and using it led households to opt for seeking medical care without the card. The value for one’s health undermined the value for the RSBY. As one household subsequent to repeated failed attempts to use the card lamented: “We lost time and money, and our illness got worse all because we wanted to use the card. I tell you, if you want to get well, if you really value your health, you cannot rely on this health card.” Next, the value of the RSBY card was derived in relation to the cultural ethos of health insurance. For a significant number of households, health insurance was perceived as a “bad omen” indicating the arrival of sickness and disease.

As the delivery of universal health care and health rights find yet another expression in India through the PMJAY scheme, it is more important than ever before to explore how citizens exercise their right to health and understand how it could be better practised. The biggest challenges for the success of the PMJAY scheme are not just financial and infrastructural at the local level, but how its value is perceived by the community.

Vani S. Kulkarni teaches sociology at the University of Pennsylvania, Philadelphia, U.S. Views are personal